Five Concepts to Fight Coronavirus

It’s hard to believe that less than six weeks have passed since the World Health Organization declared the coronavirus pandemic. We have survived the shock of hospitals as war zones, a tent hospital suddenly erected in New York’s Central Park, and thousands of deaths. Many states are winding down from peak hospitalizations. We are readying ourselves to get back to work in order to restore a fractured economy. To do so safely, we require an appropriate mindset.

The upcoming interval will be an exceptionally long period. It will require extraordinary self-discipline. This new period is the interval between the fright and chaos of COVID-19’s Wave 1, and a calm future that should come once we have an effective vaccine. This period is likely to be at least a year long, maybe closer to two years. If we get an effective treatment for COVID sooner than later, we might consider ourselves lucky. So too, if the vaccine becomes available before next spring. Otherwise, this perhaps will be the longest interlude any of us has ever spent. Here are five concepts to help us fight coronavirus over the upcoming year.

Five Concepts to Fight Coronavirus Over the Next Year

1. Respect the intelligence of the virus to attack while hiding.

I like to think of the SARS-CoV-2 coronavirus that causes COVID-19 disease as a brilliant adversary. Unlike influenza, which tends to show itself in symptoms within a couple of days of finding a receptive human, the coronavirus lays low for longer. The average time from a person picking up the infection before symptoms show is about 5 days. A study of 94 patients in China (Jan. 21 – Feb. 14, 2020[i]) found that during the incubation period before the patients got sick, they were contagious. Researchers found patients were most contagious 14 hours before symptoms showed. Further, their modeling suggested patients were contagious a full 2 to 3 days before symptoms appeared.

Knowing that infected people are contagious before feeling symptoms helps emphasize the importance of wearing cloth face coverings – homemade masks – while out in public. The virus will want you to ignore this research, so it can use you to keep attacking innocent others – doing its dirty work, so to speak. The study estimated that 44% of human to human transmission is prior to symptom onset. Let your mask be one of the tools to stop the virus’ spread. Continue to stay at home as much as possible and limit your contacts.

As we go into the year-long period before a vaccine, the virus army will not sleep. It will continue to send out probes from its hiding places. It is intelligent and clever. Virus forces will shift strategy to guerrilla war tactics. Virus snipers will take aim. We must be vigilant and on guard in our trenches. Above all, self-discipline will be important. We must maintain the strategies that have been proven to slow down the enemy.

2. Respect the speed of the virus when it finds a receptive audience.

The new coronavirus loves a receptive audience – a big group of people, the chummier, the better. The closer, the better. Give this virus a cruise ship, a business conference, or a nursing home, and it soars. So many people in one place at one time, it need not travel far to wreak havoc. Such fun this virus has when it escapes. We need to remember the early – tough – lessons from the Diamond Princess, the Life Care Center in Kirkland, Washington, and the Boston Biogen conference.

The Diamond Princess cruise ship was the first international example for how quickly the virus could spread. Departing Yokohama, Japan on January 20, 2020, the first passenger showed symptoms of coronavirus on January 25. On February 3, two weeks after the cruise began, the ship was quarantined in a Japanese port. Despite being quarantined in their cabins, the number of infected passengers grew to nearly 700 over the next 3 weeks. Ultimately, 712 people were infected and at least 12 died. The proportion infected between 2,666 passengers (median age 69) and 1,045 crew (median age 36) is not known. There were 428 Americans aboard, of which 25% tested positive. A month later, 11 US passengers were still hospitalized in Japan. Almost half of the 712 infected people were asymptomatic at the time of testing.

Life Care Center was a nursing home in Kirkland, Washington with 120 residents. Now thought to be tied to a late-February Mardi Gras party, the coronavirus rapidly infected residents, staff, and visitors. Within two weeks, this little institutional community had changed drastically – 65 residents had been transferred to hospitals; at least 13 of 15 residents testing positive for COVID died; well over 1/3 of the 180 original employees showed COVID symptoms and had to be removed from work; and the nursing home census had been reduced to 47, of which at least 26 were positive for COVID-19. According to the Centers for Disease Control, 129 people – 81 residents, 34 staff, and 14 visitors – were infected within a month. Twenty-three (23) had died. The deadly virus spread like wildfire. We have since seen this type of outbreak happen in hundreds, if not thousands of nursing homes across the United States.

Biogen was a two-day corporate meeting held at a local Boston hotel Feb. 26-27. Some executives who attended the conference were feeling ill by the weekend. Within 10 days, 70 infectious people (attendees or their close contacts) were tied to the conference in Massachusetts alone, comprising three-fourths of Massachusetts’ first 92 COVID cases. Additional attendees departed for Europe and other US states, potentially exporting the virus. Only 175 people had attended the conference. The virus must have been delighted at its success rate.

The speed of this virus is nothing short of impressive. The “R-naught” (R₀) that estimates how many people one person infects on average was thought to be 2.28 on the Diamond Princess. The February Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) estimated the R₀ in China to be “relatively high” at 2 to 2.5. Recent research by Sanche, Lin et al of Los Alamos National Laboratory (NM) calculated the R₀ at an amazing 5.7. (Early Release in CDC’s Emerging Infectious Diseases July 2020 publication.)

The implications for group workspaces and group gatherings are obvious. We will have to maintain 6-foot separation, physical distancing until we get a vaccine. Not only on the line, but in break rooms. Food processing plants (such as Smithfield Foods and Tyson Foods) have found out the hard way when hundreds of workers suddenly tested positive for the coronavirus. A major outbreak in Albany, Georgia occurred when family and friends gathered for two funerals in late February, early March. The chain of infection grew to hundreds in a matter of days and weeks. People died.

We cannot afford to have mass casualties like this in the coming year. The virus army will constantly search for quick wins in group gatherings; the bigger, the better. We must not underestimate the speed of the coronavirus.

3. Recognize this virus prefers vulnerable adults.

Perhaps we can be thankful – so far as we know – that children are not targeted by the new coronavirus. But there is no solace in the size of the audience that is vulnerable to very severe disease. The only ones “expected” to get by with just the mild or moderate form of the disease are under age 60 and without any underlying conditions. Here are some of the virus’ favorite target groups:

• Obese people – The CDC advises that those with severe obesity (BMI of 40 or higher) are at greater risk for severe COVID-19 disease. Over 9% of Americans are in this classification. But recent research also identified that obesity at a BMI of 30 or greater creates higher risk for people under the age of 60. Overall, 42% of Americans are considered obese. According to the most recent CDC report, obesity is prevalent in over 46% of men. By race, Asian Americans had only a 17.4% obesity rate, ranging to nearly 57% in non-Hispanic black women. By age group, severe obesity was highest in ages 40 to 59.
• “Elderly” people – those who were age 80+ had a case fatality rate of 14.8% (China study). Ages 70 to 79: 8.0% and 60-69 years old: 3.6%, compared to 1.3% or lower for the younger age groups. It is understood that as we age, our immune systems weaken. In the US, there are more than 50 million people age 65 and up. In addition, we have seen plenty of examples already of nursing home residents being attacked by coronavirus.
• People with common chronic illnesses like hypertension or other serious heart conditions; diabetes (affecting over 30 million adults); respiratory problems like asthma, smoking or lung disease; cancer and others with compromised immune systems. Again, the China study found the COVID-19 death rate was less than 1.0% for people with no pre-existing conditions.
• People with liver disease and those on kidney dialysis are also on the virus’ hit list.
• Men – males had a case fatality rate that was 65% higher than females in the China study. The reasons have not yet been fully researched or explained for this finding. However, in preliminary data through April 15 from New York City, men comprised 53% of cases, but 62% of deaths. Underlying conditions were present in an overwhelming majority of hospitalizations and deaths.

Racial disparities in COVID-19 death rates have also risen to top-level concern in a number of cities. The CDC is studying this now, and published a high-level analysis of death rates by race and Hispanic origin on April 14. Further information and analysis are required for a more fulsome picture.

With so many people in high-risk categories, how long will it be before everybody knows someone hospitalized with COVID-19? The virus loves to hospitalize vulnerable people.

4. Appreciate the frontline healthcare workers and others in essential jobs.

Healthcare workers have risen to the occasion to do battle with the virus. Once hospitalized, our lives are in their hands. The conditions many of them have had to endure are alarming.

Hopefully, the supply shortages are easing. For it is unconscionable to ask staff to work on the frontlines without adequate personal protective equipment (PPE). It is also not fair that doctors cannot get timely diagnostic tests for all the patients they think need to be tested. To add to such challenges, many workers have been separated from their families in order to care for patients and nursing home residents. The modest hourly wages for nursing assistants and staffing levels in long-term care facilities had no surge capacity built in. Yet, staff in overloaded healthcare facilities have displayed compassion and skill for days and weeks on end. The healthcare sector must be allowed to return to a manageable level. It needs to restore elective surgery and other delayed medical care. It should be allowed to recover and replenish before we dare test it again.

What staff cannot resolve, however, is that there is no proven treatment to cure COVID. In the end, nurses and doctors have become overwhelmed with grief at the number of deaths that cannot be stopped, despite using every available drug or ventilator. China’s experience was that almost half of severe COVID-19 patients died. Our patients died here too – 38,000 so far. They were unable to have the benefit of family at their side. Staff have brought phones and iPads to the bedside for family good-byes. There is little else that could be more heartbreaking for all involved.

Great appreciation is also in order for ambulance crews, grocery workers, community pharmacists, truck drivers, delivery staff, sanitation and housekeeping employees, police, fire department, and other workers in essential businesses. They do not have the luxury of working from home. We must plug the holes that these folks have endured – like reopening highway rest stops[ii] that were closed, or providing masks and PPE that were absent – before reopening additional parts of the economy. Some steps are extremely basic.

5. Recognize that Public Health is the virus’ biggest adversary.

Finally, defending us all against the coronavirus, are the people who work in public health. The Centers for Disease Control and Prevention (CDC); the state, county and local health departments, the National Institutes of Health, the World Health Organization (WHO), and other countries’ CDCs, who modeled theirs after the US, are unsung heroes. Quietly and without fanfare, they research, publish, and communicate what they are seeing.

By the time the first patient in the US was confirmed as positive for the 2019-nCoV[iii] virus on January 20, public health was already on it. Anthony Fauci, MD of National Institutes of Health (NIH) co-authored an opinion piece for the Journal of the American Medical Association (JAMA) on January 23. He and his colleagues noted that the World Health Organization had placed SARS-CoV on its 2017 priority pathogen list. The authors referenced that the full genomic sequence of the new virus had been shared January 10 by public health researchers from Shanghai. They pointed out that human-to-human transmission was occurring and that we were doing entry screening of passengers from Wuhan. It was clear that America was gearing up on finding antiviral drugs that might work and pursuing vaccines.

What Dr. Fauci and his colleagues could not identify, though, is what would happen next. They wrote “the trajectory of this outbreak is impossible to predict”. Consequently, the army to fight a spreading virus consisted of “classic public health strategies” of timely and effective countermeasures. Today, the public is asked to follow NPIs – non-pharmaceutical interventions:  Don’t go to work sick; wash your hands; keep six feet away from people; limit your travel and contacts; and wear a cloth face covering in public.

CDC continues to put out incredible resources. Despite testing problems, coordination with the Food and Drug Administration on expanding laboratories, and other federal government issues that will need to be sorted out, Public Health is indeed our ally in this fight. For the next year, we must work hand in hand with them. Fortunately, a March opinion poll by the Pew Research Center found U.S. public health officials, such as those at the CDC were at the top of the confidence list. Nearly eight-in-ten (79%) said these officials were doing an excellent or good job responding to the outbreak. Confidence in state and local elected officials followed next.

The American public will need to be ready to reinvest in Public Health as contact tracing is expanded. Once we reopen and cases surge in hotspots, we will have to isolate those who are positive, quarantine those who have been exposed, and trace contacts much more widely than we have done in our lifetime. Local health departments that had 10 people before may need 100. Former CDC Director, Dr. Tom Frieden, called for an expanded workforce of community health workers to do contact tracing on the order of 300,000 people. And remember, we must identify contacts that occurred two days before we showed symptoms. Whether we can use a big brother type mobile app to capture our contacts remains to be seen. In the hands of public health people, we stand a chance that our privacy will be honored.

 

Last Thoughts

There is hope on the horizon. Sixty-four thousand (64,000) people in the United States have already recovered from COVID-19. When we get widespread antibody testing up and running, we may be encouraged to learn that even more people have survived the virus.

Additionally, both private and public sectors have moved with great speed to develop antiviral drugs that work to prevent and/or treat COVID-19. A National Institutes of Health (NIH) list[iv] of clinical trials all over the world showed more than 650 trials related to COVID-19, up 40% from just five days earlier. Almost half were already recruiting participants or enrolling subjects by invitation. Dozens of trials were related to a vaccine. The speed and intelligence of our research and medical teams are a good match to the coronavirus. Impressive, indeed.

Now all we have to do, is “our part” and we will come out healthy on the other side.

Stay strong, stay safe. Embrace self-discipline.

 

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• For our favorite prediction models, questions and answers, and resources on Coronavirus and COVID-19, see Coronavirus: Current Topic of the Week  at Consumer Health Ratings

 

 

[i] “Temporal dynamics in viral shedding and transmissibility of COVID-19” by Xi He of Guangzhou Eighth People’s Hospital, Eric HY Lau of World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, University of Hong Kong, et al, posted March 18, 2020, preprint at MedRxiv.

[ii] As of April 18, 2020, 15 rest stops along Pennsylvania’s interstate or major highways were still closed.

[iii] Renamed SARS-CoV-2

[iv] Retrieved April 18, 2020, 657 clinical trials were listed as related to COVID-19.